Patient Care

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

As SHM's glycemic control lead mentor and a hospitalist at the University of New Mexico in Albuquerque, Kendall Rogers, MD, CPE, FACP, SFHM, offers advice to hospitalists when working as part of a quality team in achieving glycemic control.

As SHM's glycemic control lead mentor and a hospitalist at the University of New Mexico in Albuquerque, Kendall Rogers, MD, CPE, FACP, SFHM, offers advice to hospitalists when working as part of a quality team in achieving glycemic control.

As SHM's glycemic control lead mentor and a hospitalist at the University of New Mexico in Albuquerque, Kendall Rogers, MD, CPE, FACP, SFHM, offers advice to hospitalists when working as part of a quality team in achieving glycemic control.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Listen now to excerpts of our interview with Dr. Zelop, a board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J.

Listen now to excerpts of our interview with Dr. Zelop, a board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J.

Listen now to excerpts of our interview with Dr. Zelop, a board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Twenty years ago, pregnant women rarely appeared in the hospital for reasons other than delivery. Two trends responsible for that shift are advanced maternal age and rising rates of obesity, defined as a body mass index of >30.

The birth rate for women ages 35-44 has continued to rise, and that has brought new challenges to treating pregnancy, many of which result in hospital visits.¹

OB/GYN hospitalist Robert Olson, MD, SFHM, has witnessed the winds of change firsthand. “Older patients are more likely to have medical conditions such as hypertension and diabetes, as well as the unusual medical problems such as status post heart attack, status post heart transplant, status post chemotherapy for cancer, as well as being on medications for chronic disease,” says Dr. Olson, who practices in Bellingham, Wash., and is the founding president of the Society of OB/GYN Hospitalists.

According to the National Health and Nutrition Examination Survey, more than one third of U.S. women are obese and more than half of all pregnant women are overweight or obese and therefore prone to complications that send them to the hospital, including gestational diabetes, hypertension, and preeclampsia.³

As an inpatient, obese pregnant women present their own challenges, including increased risk of thromboembolism. When treating this type of patient, remember pneumatic compression devices are recommended if the patient will be immobile for any length of time.⁴

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Clinicians might also have significant difficulty intubating the overweight mother-to-be. Whether for cesarean section, other surgical procedures, or an acute medical crisis, physicians must approach intubation with caution as a result of excessive adipose tissue, obscured landmarks, difficulty positioning, and edema, as well as progesterone-induced relaxation of the sphincter between the esophagus and stomach.⁵ It is vital to make use of your most experienced staff when intubating this special needs patient. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
2. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist, PeaceHealth St. Joseph Medical Center, Bellingham, Wash. E-mail interview. November 13, 2013.
3. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170-178.
4. ACOG committee opinion number 549. Obstet Gynecol. 2013;121(1):213-217.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.

Twenty years ago, pregnant women rarely appeared in the hospital for reasons other than delivery. Two trends responsible for that shift are advanced maternal age and rising rates of obesity, defined as a body mass index of >30.

The birth rate for women ages 35-44 has continued to rise, and that has brought new challenges to treating pregnancy, many of which result in hospital visits.¹

OB/GYN hospitalist Robert Olson, MD, SFHM, has witnessed the winds of change firsthand. “Older patients are more likely to have medical conditions such as hypertension and diabetes, as well as the unusual medical problems such as status post heart attack, status post heart transplant, status post chemotherapy for cancer, as well as being on medications for chronic disease,” says Dr. Olson, who practices in Bellingham, Wash., and is the founding president of the Society of OB/GYN Hospitalists.

According to the National Health and Nutrition Examination Survey, more than one third of U.S. women are obese and more than half of all pregnant women are overweight or obese and therefore prone to complications that send them to the hospital, including gestational diabetes, hypertension, and preeclampsia.³

As an inpatient, obese pregnant women present their own challenges, including increased risk of thromboembolism. When treating this type of patient, remember pneumatic compression devices are recommended if the patient will be immobile for any length of time.⁴

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Clinicians might also have significant difficulty intubating the overweight mother-to-be. Whether for cesarean section, other surgical procedures, or an acute medical crisis, physicians must approach intubation with caution as a result of excessive adipose tissue, obscured landmarks, difficulty positioning, and edema, as well as progesterone-induced relaxation of the sphincter between the esophagus and stomach.⁵ It is vital to make use of your most experienced staff when intubating this special needs patient. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
2. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist, PeaceHealth St. Joseph Medical Center, Bellingham, Wash. E-mail interview. November 13, 2013.
3. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170-178.
4. ACOG committee opinion number 549. Obstet Gynecol. 2013;121(1):213-217.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.

Twenty years ago, pregnant women rarely appeared in the hospital for reasons other than delivery. Two trends responsible for that shift are advanced maternal age and rising rates of obesity, defined as a body mass index of >30.

The birth rate for women ages 35-44 has continued to rise, and that has brought new challenges to treating pregnancy, many of which result in hospital visits.¹

OB/GYN hospitalist Robert Olson, MD, SFHM, has witnessed the winds of change firsthand. “Older patients are more likely to have medical conditions such as hypertension and diabetes, as well as the unusual medical problems such as status post heart attack, status post heart transplant, status post chemotherapy for cancer, as well as being on medications for chronic disease,” says Dr. Olson, who practices in Bellingham, Wash., and is the founding president of the Society of OB/GYN Hospitalists.

According to the National Health and Nutrition Examination Survey, more than one third of U.S. women are obese and more than half of all pregnant women are overweight or obese and therefore prone to complications that send them to the hospital, including gestational diabetes, hypertension, and preeclampsia.³

As an inpatient, obese pregnant women present their own challenges, including increased risk of thromboembolism. When treating this type of patient, remember pneumatic compression devices are recommended if the patient will be immobile for any length of time.⁴

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Clinicians might also have significant difficulty intubating the overweight mother-to-be. Whether for cesarean section, other surgical procedures, or an acute medical crisis, physicians must approach intubation with caution as a result of excessive adipose tissue, obscured landmarks, difficulty positioning, and edema, as well as progesterone-induced relaxation of the sphincter between the esophagus and stomach.⁵ It is vital to make use of your most experienced staff when intubating this special needs patient. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
2. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist, PeaceHealth St. Joseph Medical Center, Bellingham, Wash. E-mail interview. November 13, 2013.
3. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170-178.
4. ACOG committee opinion number 549. Obstet Gynecol. 2013;121(1):213-217.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.

Gordon Guyatt, MD, who coined the term evidence-based medicine in a 1992 JAMA article, outlined EBM principles and challenged hospitalists to challenge the research.

Gordon Guyatt, MD, who coined the term evidence-based medicine in a 1992 JAMA article, outlined EBM principles and challenged hospitalists to challenge the research.

Gordon Guyatt, MD, who coined the term evidence-based medicine in a 1992 JAMA article, outlined EBM principles and challenged hospitalists to challenge the research.

From early-career hospitalists looking to gain hands-on experience with intraosseous lines to family-medicine trained physicians brushing up on ultrasound usage, the procedures' pre-courses at SHM annual meetings receive rave reviews.

From early-career hospitalists looking to gain hands-on experience with intraosseous lines to family-medicine trained physicians brushing up on ultrasound usage, the procedures' pre-courses at SHM annual meetings receive rave reviews.

From early-career hospitalists looking to gain hands-on experience with intraosseous lines to family-medicine trained physicians brushing up on ultrasound usage, the procedures' pre-courses at SHM annual meetings receive rave reviews.

Despite huge strides in the treatment of heart failure, pneumonia and myocardial infarction, hospitals have a long way to go in improving care for patients with sepsis, say the authors of a recent commentary published online in JAMA.

In a related study published in July in JAMA, sepsis was found to contribute to one in every two to three hospital deaths based on mortality results from two independent patient cohorts measured between 2010 and 2012. Additionally, most instances of sepsis were present upon admission, the report notes.

For their part, hospitalists should focus on identifying the signs and symptoms of sepsis early, according to study authors Colin R. Cooke, MD, MSc, MS, and Theodore J. Iwashyna, MD, PhD, of the division of pulmonary and critical care medicine at the University of Michigan in Ann Arbor.

"When patients are admitted for an illness such as pneumonia, we put them in a bin where we know how to treat patients with pneumonia, but we may fail to recognize when they meet the criteria for sepsis," Dr. Cooke says. "If we can recognize a patient has sepsis, then we can get on top of the illness faster by delivering antibiotics and also ensuring the patient gets fluid resuscitation early in the course of the disease."

In their JAMA article, Dr. Cooke and Dr. Iwashyna call on the Centers for Medicare & Medicaid Services to develop quality mandates that would encourage hospitals to share best practices in treating sepsis. The mandates, however, shouldn't include financial penalties, which the authors say "would create perverse incentives to not report delayed diagnosis of sepsis rather than address the problem."

Visit our website for more information on identifying sepsis in hospitalized patients.

Despite huge strides in the treatment of heart failure, pneumonia and myocardial infarction, hospitals have a long way to go in improving care for patients with sepsis, say the authors of a recent commentary published online in JAMA.

In a related study published in July in JAMA, sepsis was found to contribute to one in every two to three hospital deaths based on mortality results from two independent patient cohorts measured between 2010 and 2012. Additionally, most instances of sepsis were present upon admission, the report notes.

For their part, hospitalists should focus on identifying the signs and symptoms of sepsis early, according to study authors Colin R. Cooke, MD, MSc, MS, and Theodore J. Iwashyna, MD, PhD, of the division of pulmonary and critical care medicine at the University of Michigan in Ann Arbor.

"When patients are admitted for an illness such as pneumonia, we put them in a bin where we know how to treat patients with pneumonia, but we may fail to recognize when they meet the criteria for sepsis," Dr. Cooke says. "If we can recognize a patient has sepsis, then we can get on top of the illness faster by delivering antibiotics and also ensuring the patient gets fluid resuscitation early in the course of the disease."

In their JAMA article, Dr. Cooke and Dr. Iwashyna call on the Centers for Medicare & Medicaid Services to develop quality mandates that would encourage hospitals to share best practices in treating sepsis. The mandates, however, shouldn't include financial penalties, which the authors say "would create perverse incentives to not report delayed diagnosis of sepsis rather than address the problem."

Visit our website for more information on identifying sepsis in hospitalized patients.

Despite huge strides in the treatment of heart failure, pneumonia and myocardial infarction, hospitals have a long way to go in improving care for patients with sepsis, say the authors of a recent commentary published online in JAMA.

In a related study published in July in JAMA, sepsis was found to contribute to one in every two to three hospital deaths based on mortality results from two independent patient cohorts measured between 2010 and 2012. Additionally, most instances of sepsis were present upon admission, the report notes.

For their part, hospitalists should focus on identifying the signs and symptoms of sepsis early, according to study authors Colin R. Cooke, MD, MSc, MS, and Theodore J. Iwashyna, MD, PhD, of the division of pulmonary and critical care medicine at the University of Michigan in Ann Arbor.

"When patients are admitted for an illness such as pneumonia, we put them in a bin where we know how to treat patients with pneumonia, but we may fail to recognize when they meet the criteria for sepsis," Dr. Cooke says. "If we can recognize a patient has sepsis, then we can get on top of the illness faster by delivering antibiotics and also ensuring the patient gets fluid resuscitation early in the course of the disease."

In their JAMA article, Dr. Cooke and Dr. Iwashyna call on the Centers for Medicare & Medicaid Services to develop quality mandates that would encourage hospitals to share best practices in treating sepsis. The mandates, however, shouldn't include financial penalties, which the authors say "would create perverse incentives to not report delayed diagnosis of sepsis rather than address the problem."

Visit our website for more information on identifying sepsis in hospitalized patients.